Finding into death of Robert Albert Burns

Contributing factors

• Delay in considering and excluding intra-abdominal cause including anastomotic leak as underlying cause from day 3 to day 8 post-surgery
• Delay in performing CT scan of abdomen until day 8 post-surgery
• Possible delay in acting on CT scan results and ensuring timely transfer to tertiary centre
• CT scan obtained on day 8 but transfer to St Vincent's not until day 10
• Absence of documented multidisciplinary meetings and joint decision-making between medical and surgical teams
• Different specialist ward rounds at different times with varying clinical assessments
• Reliance on clinical assessment to dismiss intra-abdominal problem rather than imaging investigation
• Initial failed attempt to transfer to Geelong ICU due to need for permacath at tertiary centre

Coroner's recommendations

1. Conduct a review of approach to deteriorating and 'not progressing' post-operative colorectal surgical patients with a view to reliably and consistently applying the recommendations of the Victorian Surgical Consultative Council
2. Implement multi-disciplinary consultant ward rounds or management meetings in ICU, particularly with regards to unstable or deteriorating patients with multiple potential problems who are failing to respond to treatment as expected
3. Implement a policy of surgical 'peer review' of deteriorating or non-progressing patients
4. Implement a policy whereby failed attempts by junior medical staff to transfer a patient to a higher level of care are escalated to a consultant to ensure timely transfer by discussion between peers at the sending and receiving hospital
5. Implement a policy of direct surgeon to surgeon communication when a complicated and/or deteriorating patient is in need of transfer for care by another surgeon at another hospital